Synopsis
Build a proportionate preoperative plan that improves physiological reserve, treats modifiable disease and supports informed joint-surgery decisions without creating harmful or arbitrary delay.
- Begin optimisation when referral for joint replacement is made, because anaemia treatment, smoking cessation, conditioning and shared decisions need weeks rather than a final-day checklist.
- First-line assessment combines procedure risk with frailty, functional capacity, comorbidity, medicines, nutrition, cognition, social support and the patient's goals and acceptable trade-offs.
- Use NICE NG45 to select preoperative tests by operation grade and comorbidity; routine panels in every patient create false positives without replacing history and examination.
- Identify and investigate anaemia early, including iron studies where indicated; choose oral or intravenous iron from cause, severity and time available rather than treating the haemoglobin value alone.
- For diabetes, obtain a recent HbA1c and aim for optimisation below 69 mmol/mol when safely achievable, but use individual risk and urgency rather than an automatic cancellation rule.
- Offer practical preparation: progressive activity within joint limits, adequate protein and energy intake, weight-management support, smoking cessation and alcohol moderation without shaming or withholding care.
- Create an explicit perioperative medicine plan for anticoagulants, antiplatelets, insulin, SGLT2 inhibitors, steroids and other high-risk drugs, coordinated with anaesthesia and prescribers.
- Proceed, defer or choose non-operative care through shared decision making that compares expected benefit, residual symptoms, personalised complication risk and the harm of further delay.
Key red flags
Rest chest pain, syncope on exertion, new pulmonary oedema or an unstable arrhythmia requires urgent cardiovascular assessment before elective anaesthesia.
Fever, spreading cellulitis, an infected ulcer or active infection near the planned joint raises prosthetic infection risk and needs prompt diagnosis and treatment.
Severe symptomatic anaemia, ongoing blood loss or unexplained cytopenia needs cause-directed investigation rather than transfusion or iron prescribed without a diagnosis.
Polyuria, vomiting, ketones, severe hyperglycaemia or recurrent hypoglycaemia may represent diabetic decompensation and must be managed before routine surgery planning.
A painful swollen calf, unexplained hypoxia or pleuritic chest pain before surgery requires an urgent venous-thromboembolism pathway, not reassurance from an upcoming operation.
Rapid loss of function, rest pain, destructive radiographic change or systemic illness should trigger reconsideration of infection, fracture or malignancy rather than routine arthroplasty scheduling.
Investigation priorities
Identify active disease, frailty, functional limitation, airway and social factors that can change anaesthesia, surgery or recovery.
Management branches
Major hip, knee or shoulder joint surgery is being considered.
- Confirm indication, alternatives, expected benefit and the outcomes that matter to the patient.
- Assess frailty, function, comorbidities, medicines, anaemia risk, diabetes, nutrition, smoking, alcohol and home circumstances.
- Begin exercise, nutritional and lifestyle support within safe joint limits and refer promptly for treatable abnormalities.
- Give a named contact and timeline so optimisation proceeds alongside surgical planning rather than after listing.